3.1.2 Antimuscarinic bronchodilators

Advice on how to obtain placebo inhalers can be obtained from the NHS Devon CCG Medicines Optimisation Team, please contact: d-ccg.medicinesoptimisation@nhs.net

Generic prescribing of inhalers should be avoided as this might lead to patients being given an unfamiliar inhaler device which they are not able to use properly; in addition, not all inhalers with the same primary ingredient are interchangeable due to differences in particle size.

Patient preference should be considered when prescribing treatments. It is essential that patients can demonstrate the proper inhaler technique when prescribing an inhaler device; recheck patient technique at each visit to ensure continued correct use of the inhaler. Adherence to treatment regimens should also be checked. When discussing inhaled treatment options, consideration should also be given to the environmental impact of inhalers.

NICE has produced a patient decision aid to help people with asthma and their healthcare professionals discuss their options for inhaler devices (available here); it is suitable for use by people aged 17 years and over, and many of the considerations are also applicable to patients with COPD.

pMDI = Pressurised metered dose inhaler; DPI = Dry powder inhaler; SMI = Soft mist inhaler

When prescribing a pressurised MDI, remind patients to check and remove the mouthpiece cover fully, shake the inhaler to remove loose objects that may not be visible, and check the inside and outside of the mouthpiece are clear before inhaling a dose. To prevent objects entering the mouthpiece during storage, the mouthpiece cover should be replaced securely after use. See MHRA Drug Safety Alert July 2018 for further details.

Short-acting muscarinic antagonists (SAMAs)

Ipratropium Bromide
  • Atrovent® aerosol inhalation 20 micrograms/ metered inhalation (pMDI) (£5.56 = 200 doses)
  • Nebuliser solution 250 micrograms in 1ml (£2.88 = 20 x 2ml unit dose vials)

Indications and dose

  • Chronic obstructive pulmonary disease
    • By aerosol inhalation, 20–40 micrograms 3–4 times daily
    • By inhalation of nebulised solution, reversible airways obstruction in chronic obstructive pulmonary disease, 250–500 micrograms 3–4 times daily

Notes

  1. Acute angle glaucoma may occur with ipratropium particularly when used in a nebuliser with salbutamol. Care should be taken to avoid escape from the mask into the eyes.
  2. pMDIs have a significantly higher carbon footprint than DPIs and SMIs (refer to the environmental impact of inhalers)

Long-acting muscarinic antagonists (LAMAs)

Braltus® Zonda®

(Tiotropium)

  • 10 microgram inhalation powder, capsule (DPI) (£25.80 = 30 days)

Indications and dose

Notes

  1. The Braltus® Zonda® inhaler is not licensed for use in patients with asthma
  2. The MHRA update below also applies to tiotropium delivered by the Zonda® device.
  3. MHRA Drug Safety Update (February 2015): When using tiotropium delivered via Respimat® or Handihaler® to treat chronic obstructive pulmonary disease (COPD):
    1. take the risk of cardiovascular side effects into account for patients with conditions that may be affected by the anticholinergic action of tiotropium, including:
      • Myocardial infarction in the last 6 months
      • Unstable or life threatening cardiac arrhythmia
      • Cardiac arrhythmia requiring intervention or a change in drug therapy in the past year
      • Hospitalisation for heart failure (NYHA Class III or IV) within the past year
    2. tell these patients to report any worsening of cardiac symptoms after starting tiotropium; patients with these conditions were excluded from clinical trials of tiotropium, including TIOSPIR
    3. review the treatment of all patients already taking tiotropium as part of the comprehensive management plan to ensure that it remains appropriate for them; regularly review treatment of patients at high risk of cardiovascular events
    4. remind patients not to exceed the recommended once daily dose
  4. MHRA Drug Safety Update (May 2018): Braltus® (tiotropium): risk of inhalation of capsule if placed in the mouthpiece of the inhaler
    1. Train patients in the correct use of their Zonda® inhaler; a placebo device is available for training purposes and instructions for patients are provided in the patient information leaflet and on the carton
    2. Tell patients to store capsules in the screw-cap bottle provided (never in the inhaler) and to always check the mouthpiece is clear before inhaling
  5. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers)
Spiriva® Respimat®

(Tiotropium)

  • 2.5 microgram/dose solution for inhalation (SMI) (£23.00 = 30 days)

Indications and dose

Notes

  1. MHRA Drug Safety Update (February 2015): When using tiotropium delivered via Respimat® or Handihaler® to treat chronic obstructive pulmonary disease (COPD):
    1. take the risk of cardiovascular side effects into account for patients with conditions that may be affected by the anticholinergic action of tiotropium, including:
      • Myocardial infarction in the last 6 months
      • Unstable or life threatening cardiac arrhythmia
      • Cardiac arrhythmia requiring intervention or a change in drug therapy in the past year
      • Hospitalisation for heart failure (NYHA Class III or IV) within the past year
    2. tell these patients to report any worsening of cardiac symptoms after starting tiotropium; patients with these conditions were excluded from clinical trials of tiotropium, including TIOSPIR
    3. review the treatment of all patients already taking tiotropium as part of the comprehensive management plan to ensure that it remains appropriate for them; regularly review treatment of patients at high risk of cardiovascular events
    4. remind patients not to exceed the recommended once daily dose
  2. SMIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers)
Seebri® Breezhaler®

(Glycopyrronium bromide)

  • 55 microgram inhalation powder, hard capsule (DPI) (£27.50 = 30 capsules plus device)

Indications and dose

Notes

  1. The commissioning of glycopyrronium inhaled therapy is accepted in Devon for the maintenance treatment of patients with Chronic Obstructive Pulmonary Disease (COPD) who require a long acting bronchodilator (see Commissioning Policy for more details)
  2. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers)
Eklira® Genuair®

(Aclidinium bromide)

  • Inhalation powder 375 micrograms (DPI) (£32.50 = 60 dose unit)

Indications and dose

Notes

  1. There is a lack of robust published evidence directly comparing aclidinium to other bronchodilators and a lack of good quality long term data on efficacy for aclidinium. Because of this it is recommended that aclidinium is reserved for patients who cannot tolerate the first line LAMAs
  2. The commissioning of aclidinium inhalation powder is accepted in Devon for the maintenance treatment of patients with Chronic Obstructive Pulmonary Disease (COPD) who require a long acting bronchodilator (see Commissioning Policy for more details)
  3. DPIs have a significantly lower carbon footprint than pMDIs and BAIs (refer to the environmental impact of inhalers)
Last updated: 13-11-2019

 

Home > Formulary > Chapters > 3. Respiratory > 3.1 Bronchodilators > 3.1.2 Antimuscarinic bronchodilators

 

  • First line
  • Second line
  • Specialist
  • Hospital